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Frontal Sinus Surgery

Listed below is the step by step procedure of frontal sinus surgery:

  1. What is Frontal Sinus Surgery ?
  2. Why is Frontal Sinus Surgery Required?
  3. Pre-operative Preparation
  4. Day Before Surgery
  5. Procedure Day
  6. Methods/Techniques of Frontal Sinus Surgery
  7. Post Procedure
  8. Risks and Complications

What is Frontal Sinus Surgery?

Sinuses are mucosa lined air filled cavities in the skull and face. It is because of sinuses that our skull feels lighter. Frontal sinuses are cavities that are found behind the brow-ridges. Sometimes the frontal sinuses get inflammed (sinusitis) or have blockages (polyps, bony growths etc.) that cannot be treated with conventional methods. In such cases, frontal sinus surgery is done to remove these infections and obstructions. An endoscope is used to view the sinuses from within and surgical instruments are used to clear the area.

Why is Frontal Sinus Surgery Required?

When all non-invasive methods of treatment have failed, surgery is the final option to treat the problem. Here is a possible list of the factors that may lead to frontal sinus surgery -

  • Chronic Sinusitis: Swelling and inflammation of sinus cavities for a long period of time, or frequent attacks of smaller duration
  • Enlarged Turbinates: Swollen nasal turbinates present with breathing difficulty and recurrent sinus infections.
  • Choanal atresia: It is a congenital disorder where there is narrowing or blockage of nasal airway. This leads to recurrent nasal and sinus infections.
  • For closure of CSF rhinorrhea leak points
  • To remove nasal polyps (antrochoanal, ethmoidal polyps)
  • Acute Sinusitis
  • In matters of diagnostic importance such as evaluation of CSF rhinorrhea, pointing out location of epistaxis, etc.
  • To correct septal deviations.
  • To remove mucopyocoele (cyst filled with pus)
  • In cases of severe trauma, maxillofacial injuries (injuries of the face and jaws)

Pre-Operative Procedure

  • The nose is a very vascular part (has a rich blood supply) and is in close proximity to the frontal sinus. Thus it is important to avoid medications that may enhance the chance of a nosebleed after surgery.
  • Aspirin, other non-steroidal anti inflammatory drugs, vitamin E, warfarin etc. thin the consistency of blood and should be stopped two weeks prior to surgery.
  • Blood pressure (BP) also should be controlled two weeks prior to surgery because it can create a nosebleed.
  • Tobacco smoke can irritate the nasal passageway. If you are a smoker, it is advisable to stop smoking a 10-14 days prior to surgery. Smoking delays wound healing.
  • If you had previously suffered freom any serious disease, do let your doctor know about it. Any history of cardiac disease, a stent or a bypass surgery, diabetes, respiratory, liver and kidney disorders are of importance.
  • If you are on any medications, keep your doctor in the loop.

Diagnosis :

Frontal sinus conditions can be evaluated with the help of following tests:

  • Blood examination: Blood samples are taken to check for the presence of bacterial, viral infections, blood sugar levels etc.
  • Mucus samples: They can be used for identification of pathologies.
  • Skin test: Used to pinpoint allergy causing substances
  • Imaging tests: Computed Tomography scans help in locating the exact site of the polyps, tumors, cysts etc.
  • Endoscopic Nasal Evaluation: A flexible fiber optic structure light is inserted through the nose to check smallla bnormalities in the sinuses.
  • Tissue can be obtained from sinuses and nose for microscopic examination. Tissue culture can be done to check for disease causing micro-organisms.
  • Sinus punctures are done to withdraw samples and bacterial cultures are performed on them. Prior to surgery, your anesthesiologist would ask you to perform a series of tests to check your fitness levels before the surgery.
  • Blood tests: These include Complete Blood Count (CBC), blood pressure (BP), blood sugar, erythrocyte sedimentation rate (ESR), etc.
  • Urinalysis: Presence of sugar, albumin (protein), pus cells in urine is done. Color, consistency, specific gravity of urine are measured.
  • Electrocardiogram (ECG): Measures electrical activity of heart on a graph paper.
  • Liver Function Tests: Bilirubin tests, levels of aspartate and alanine transferases (AST, ALT) are calculated. A majority of drugs are metabolised via the liver and hence its sound functioning is necessary.
  • Renal Function Tests: Blood Urea Nitrogen (BUN), creatinine, creatinine clearance rate are checked to rule out any kidney damage.

Day Before Frontal Sinus Surgery

  • You can take a nice bath and shampoo your hair before the surgery. Wash your face with soap.
  • When you come to the surgical center wear some comfortable and loose clothing, preferrably those which can be opened from the front. You should avoid pulling clothes over the nose and head after a sinus surgery.
  • You can leave your valuables at home. Don't wear any make-up or nail polish. Keep your contact lenses at home.
  • Bring some things which can help you pass your time once you are into recovery.
  • Be sure to be accompanied with someone who will stay with you throughout the surgery.
  • Remember to arrange for some conveyance to drop and pick you from the surgical center.
  • Follow your anesthesiologist's instructions and do not eat anything 8-12 hours before surgery.

Procedure Day

Your doctor will review the entire process of surgery with you. Feel free to ask him/her any doubts you may have.

  • The nursing team will again check your vitals (BP, pulse, temperature, blood tests, ECG).
  • Before going in for the surgery you will be asked to sign a consent form. It outlines the procedure and possible risks and complications.
  • You will be given a clean surgical gown to wear and then taken to the operation theater. The operation theater is well disinfected and equipped with sterelised instruments.
  • After this the anesthesia will be administered to you.

Methods/Techniques of Frontal Sinus Surgery

Anesthetic Considerations:

  • Most of ENT surgeries (Ear Nose Throat) surgeries can be performed under both local and general anesthesia.
  • The use of local or general anesthesia is dependent on the procedure performed and the patient requirements.
  • Local anesthesia numbs only a specific area/region of the body. You would hence be awake during the surgery. Sedatives (sleep inducing drugs) are given to you so that you remain comfortable and unaware about what happened during the surgery.
  • Lignocaine is the preferred anesthetic agent with adrenaline to prolong its activity. Sedatives are given via I/V infusions.
  • General anesthesia is given either by inhalation or with the help of an I/V line. The induction is done mostly with fentanyl and propofol.
  • Your surgeon would put a laryngeal airway mask into your mouth. It acts as a breathing tube as well as preventing any aspiration (pooling) of fluids.
  • The anesthesiologist will continuously monitor the heart rate, respiration rate, BP to ensure no complications arise once the anesthesia is given.

The Procedure :

Frontal sinus surgery techniques are varied and depends on the anatomy and severity of the disease. We will study a few methods used in relieving the sinuses.

The aims of frontal sinus surgery are -
  • The underlying disease must be eradicated.
  • The anatomy of the frontal sinus should be preserved.
  • There should be minimal or no cosmetic deformity.

These techniques are just an outline. A detailed discussion with your doctor will give you the best solution.

  • Functional Endoscopic Sinus Surgery (FESS): This method has gained a lot of popularity recently due to its non-invasiveness and better post-op results. It is usually performed under local anesthesia but can be performed under a general anesthesia as well. It is done on an outpatient basis. With this technique, normal sinus function is restored. If you have been suffering from chronic sinusitis, then you are a likely candidate for this approach.

    A tube like structure is inserted through your nose which is fitted with a camera on the top. This is called an endoscope. The sinus cavities are visualized using this and any polyps, obstructions or inflamed mucus linings are removed using special instruments.

    This creates a clear pathway for the mucus to drain properly. The nose is later covered with a dressing on both sides.

    The best part about this surgery is that there are no incisions on the face.

    1. Rhinofrontal Sinus Septostomy: It is a combined 'intra-extra' nasal approach. Here grafts are used to rejuvenate the frontal sinus drainage area. This technique is used in those cases where frontal sinus disease reappears even after surgical treatment. The connection between the frontal sinus and nasal cavities is enlarged and new mucosal grafts are applied. Revision surgeries are not required after using this technique.

    2. Cranialization Of Frontal Sinus: This approach is indicated in cases of trauma to the frontal sinus, destruction of it's posterior wall, presence of any intracranial foreign body, etc. Here the destroyed posterior (back) wall and mucosa of the frontal sinus are removed after exposing the mid forehead and eyebrow areas. After this, the fractured areas are repaired with plating and the anterior bone fragments are realigned according to the contour of the forehead.
    3. Osteoplastic Flap Procedure: It is the preferred surgical approach to frontal sinus in cases of external operations and is useful in removal of benign tumors,. Using this technique, a flap is raised over the region of frontal sinus (from the temples to below the brow ridge.). The mucosa is removed, the bone below is drilled and the sinus cavity is drained. After this using facial tissues and fibrin glue, the sinus cavity is filled with fat and packed with sponge.

    4. Endonasal Surgery Of Frontal Sinus:

      This technique has 3 different types of approaches (drainage patterns).

      • Type 1 drainage: Used when acute rhinosinusitis (inflammation of nose and frontal sinuses) is unable to resolve using conservative surgery, in chronic rhinosinusitis and as a revision surgery for incomplete ethmoidectomy.
      • Type 2 drainage: Used to remove cysts, tumors and to treat serious complications of acute rhinosinusitis.
      • Type 3 drainage: In difficult revision surgeries, polyposis (formation of polyps) and cystic fibrosis.

    5. Axillary Flap Approach: This technique is suggested to be a better alternative to endonasal frontal sinus surgery because it overcomes the problems faced in the latter procedure. The agger nasi (a small bridge near the nasal cavity) cells are taken out when they come too close near the frontal sinus. Though more time consuming in nature, this technique allows for exposure of a large part of frontal sinus with the help of a small telescope. On an average, a frontal sinus surgery takes about 2-3 hours to reach completion.

    Post-Operative Procedure

    The recovery period holds different meaning for different people. Some people can heal very quickly whereas some recover at their own pace. This is nothing to worry about, as everyone is different. On an average recovery takes a few days to a month, but following home care instructions to the letter.

    • You will be taken to a recovery room and allowed to rest till your general anesthesia wears off.
    • Since your nose would be packed, you will need to breathe from your mouth.
    • Secretions like blood, mucous are normal for the first few days. Spit them out and don't swallow them.
    • You would feel a little tired for a day or two.
    • Your vitals will again be checked by the nursing staff.
    • You will be able to eat food when the nurse deems you fit to do so. Have some light food for the first few days and drink more fluids.
    • Your doctor will advise you on the things you have to take care of once you go back home. It is important that you follow these instructions to promote quicker healing.
    Other home care instructions are as follows -

    • Diet:
      You must have a healthy diet. Bland to normal food is fine. Hot and spicy foods can trigger the inflammation and slow down healing of the site. Whenever you drink fluids, avoid the use of straw.

    • Activity:
      A one week off is good for recovery. Try not to blow your nose in the first week after surgery. Do not lift heavy weights and avoid any unnecessary bending movements. Light exercises such as walking are beneficial, as they keep your bowel movements stable after the effect of general anesthesia. Sleep with your head elevated. You can prop your head with a few pillows while sleeping or lying down.

    • Medications:
      Follow your prescriptions exactly as advised by the doctor. You can resume your normal medications. But avoid taking aspirin, ibuprofen and other NSAIDS (Non Steroidal Anti-Inflammatory Drugs) for at least 10 days after surgery.

      You would be given antibiotics to control the infection, but diarrhea is a common side effect of these drugs. If you find the diarrhea troubling you too much, ask your doctor for a milder alternative.

      Use an ice-pack to decrease the swelling of the nose and surrounding areas . Oxymetazonine sprays are heplpful in times of post operative bleeding. Take steam inhalations daily.

    Risks and Complications

    The risks and complications of frontal sinus surgery can be divided into two categories:

    1. General complications
    2. Complications associated with frontal sinus surgery

    1. General Complications:
      • Anesthesia: There can be nausea, vomiting, respiratory depression, coma etc.
      • Cardiac: Risk of stroke, cardiac arrest (heart attack)
      • Anaphylaxis: It is a severe form of allergy which can manifest as oedema, swelling, redness etc.
      • Bleeding: Loss of blood can be during or even after the surgery. A reserve of the same blood group is usually kept handy. Nasal packing is of help in post operative bleeding.

    2. Complications associated with frontal sinus surgery:
      • The eye and its socket (orbit) can get damaged. The optic nerve is at risk of being damaged too. Orbital hematoma (localised collection of blood near the eye socket) is seen.
      • Double vision (diplopia) due to accidental injection of anesthetic into the eye
      • Damage to skull, especially the basal part.
      • Brain abscess and meningitis can arise.
      • The nose can get obstructed due to failure to remove polyps.
      • The infection cannot get controlled.
      • Trauma to eye can lead to synechiae formation ( the iris adheres to cornea or lens).
      • The great vessels such as the carotid artery may get injured.
      • Injury to naso-lacrimal duct is possible.
      • Because of intimate connection of frontal sinus with the brain, any trauma to the former may cause leakage of cerebrospinal fluid (CSF) also known as CSF rhinorrhea.
      • There are chances of recurrent infection and hence the need to undergo surgery again.
      • Temporary changes in voice pattern

    If you observe any of the following symptoms, contact your doctor at the earliest:
    • Unexplained fever
    • Excessive bleeding from your nose
    • The pain does not subside even after taking pain-medications.
    • There is a lot of drainage from the nose, along with sneezing.
    • You experience double vision, swelling of the eyes and a stiff neck.
    • You feel fatigued

    Follow up

    Follow-ups are very important after a frontal sinus surgery. You may be recalled by your doctor about a week after surgery. These are necessary because debridement (cleaning) needs to be carried out for sometime to remove the mucus and blood buildup in the nose. Initially, three visits over the first 6 weeks would be the plan. Then your visits will become less frequent over the months, according to the healing of the sinuses.

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